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Decreasing re-hospitalizations and emergency department visits in persons with recent spinal cord injuries using a specialized medical home

The Journal of Spinal Cord Medicine, 2021 · DOI: 10.1080/10790268.2019.1671075 · Published: March 1, 2021

Spinal Cord InjuryHealthcareRehabilitation

Simple Explanation

This study explores whether a specialized medical home can help people with spinal cord injuries (SCI) avoid returning to the hospital or emergency department (ED) in the first year after they leave inpatient rehabilitation. The medical home provided comprehensive support, including pre-discharge communication, medication education, a 24/7 hotline, and multidisciplinary outpatient follow-up. The results suggest that these interventions may indeed reduce the rate of readmission and ED visits for SCI patients.

Study Duration
Three-year
Participants
176 individuals with varying levels of SCI
Evidence Level
Not specified

Key Findings

  • 1
    Thirty percent of the individuals were readmitted within the first year after discharge from an IRF, and 24% were readmitted within the first year after onset.
  • 2
    The incidence of readmission was 0.46 within one year of IRF discharge and 0.36 within one year of onset.
  • 3
    Forty-one percent of the 176 participants visited the ED within the first year after discharge from an IRF, and 36% visited the ED within the first year after onset.

Research Summary

This study investigated the impact of a specialized medical home on reducing re-hospitalizations and emergency department (ED) visits for individuals with spinal cord injury (SCI) in the first year post-discharge from acute inpatient rehabilitation. The interventions included pre-discharge communication, medication education, a 24/7 hotline, multidisciplinary outpatient follow-up, and proactive case management. The results suggest that the medical home interventions decreased the rate and incidence of readmission and the rate of ED usage in the first year.

Practical Implications

Improved Patient Outcomes

A specialized medical home model shows promise in reducing re-hospitalizations and ED visits for individuals with SCI, leading to improved patient outcomes and quality of life.

Cost Savings

By decreasing re-hospitalizations and ED visits, the medical home model has the potential to reduce healthcare costs associated with SCI management.

Model for Other Populations

The principles of the SCI specialized medical home could be adapted and applied to other populations with chronic conditions or disabilities to improve care coordination and reduce healthcare utilization.

Study Limitations

  • 1
    Data from this study were collected from patients discharged from a single rehabilitation hospital and may not be generalizable.
  • 2
    The data are not fully accurate due to reliance on patient report for some outcomes.
  • 3
    The lack of baseline data make definitive conclusions about the effectiveness of the intervention impossible.

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